Failure

[Janders]

We gonna discuss this?

The American Board of Emergency Medicine (ABEM) released the results of the 2024 Qualifying Examination (QE) on Monday, November 25, 2024. The pass rate for first-time test takers is 82%, and for all test takers, the pass rate is 80%. This is lower than 2023 (88% and 86% respectively) and follows a multi-year trend.

ABEM recognizes that failing the QE has a significant impact on physicians who now will need to re-take the QE. We understand the downstream impacts of failing the exam this year.

During the over two years of stakeholder feedback during the Becoming Certified Initiative, ABEM heard from the specialty that maintaining high standards was of paramount importance. ABEM is committed to these high standards by maintaining the current standard for the QE.

This examination was not more difficult. The passing standard for the QE was determined in 2019. Since then, all subsequent exams have been psychometrically equated to this standard which means the exam difficulty has remained unchanged since 2019. Due to the magnitude of this year’s decline, ABEM verified that this is a real decline in performance and not a function of a more difficult examination or other measurement issue.

This year’s QE exam performance result follows a six-year trend of declining performance on both the In-Training Examination (ITE) and the QE. ABEM is committed to working with the EM community to identify factors associated with a decline in examination performance.

ABEM seeks to answer questions and provide support on the next steps for all physicians in the certification process. Candidates and others with questions are encouraged to contact [email protected].

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[RustedFox]

HotTake: Skill issue, git gud.
The kids are being coddled too much.
Especially at HCA Residency, where learning comes last.

 

[Porfirio]

Just not good for our specialty overall.

1) Students suck because of dilution of teaching/educator pool
2) Horrible quality of new residencies
3) Going to be a huge push to dumb down the standards
4) Mad rush to complete within 5 years

 

[CoolDoc1729]

It’s almost like if you put lower quality candidates into lower quality residency programs you would get lower quality EPs, or something. Weird.

 

[TooMuchResearch]

Exactly. Don't try to tell them that on Reddit though. "Boohoo test too hard not fair bad test test's fault boohoo."

 

[JAFERD_MD]

Exactly. Don't try to tell them that on Reddit though. "Boohoo test too hard not fair bad test test's fault boohoo."

The new generation response is "It's biased and racist and not a fair representation of my skills as a clinician and first-generation low income immigrant minority with a real understanding of my patients' needs."

 

[LibBum]

I went to a well established (none ivory tower named) program in the south, finishing at the end of June at the age of 38 with in-service exam scores that were trash. Started working community EM in July and grinding Rosh. Was fortunate to hit my predicted score of 80 after a few ****ty months of working/studying. It's a lame exam, but Rosh and residency got me over the hurdle. Everyone wants their coin and ABEM is part of the process - for better or worse.

 

[hoot504]

Shoot I'll add some more kindling to this. The new hires we've had come on since I graduated residency in 2018 absolutely trend lower in clinical competency. We staff 4 hospitals in a major metro and have had 4-5 huge rounds of hiring dating back the past 6 years. It's almost getting to be the exception rather than the rule that a new hire finds their footing and doesn't have any issues. A lot of our new hires are slow at best, occasionally incompetent at worse and not particularly trusted by the nursing staff.

 

[JacobMcCandles]

Maybe it's just the old man in me but that seems to reflect the average new grad. I wish there was a way to assess department management because most of the newer grads struggle with this. There are a few superstars but they're the exception and not the rule.

 

[hopeful22213]

Plenty of watering down with all the new CMG/PE/corporate widget residencies (cough *HCA* cough) but I also get people's skepticism about ABEM's motivations. I think we all welcome strict standards regarding EM fund of knowledge but this is the same ABEM adding a new certifying exam in 2026 to test "communication" and "leadership" skills...that will only be administered at one site in North Carolina, famed beacon of easy domestic travel. I have no doubt the price tag will be another kick in the pants for new grads.

I don't trust these new residencies but I also don't trust ABEM. After all, it's hard to teach a man something if his salary depends upon him not knowing it.

 

[hopefulERdoc251]

As a PGY3 who graduated last year, passed the ABEM cert exam, I agree that doing rosh review probably would've gotten you a pass. I also agree that the quality of residents did go down as I looked at my PGY2 and 1 class. There's no way to getting around needing to memorize facts, we all did it for USMLE 1/2/3 or COMLEX.

I don't think the answer is as simple as the younger generation is more entitled etc. I think it's a bit more complicated than that. I think that there are definitely weak links that are not the strongest clinically and have an entitled mentality. I do think that my group, the year above and the year below us had really unique circumstances regarding COVID. There was change to our clinical curriculum that led to less in person rotations. Some people had no away rotations and got SLOE's from their home programs which probably didn't accurately represent the quality of the candidate (who wants to torpedo an applicant in the midst of an unprecedented application cycle).

Coming into residency, we initially faced a mix of low volume and then the subsequent mass flux of chronically ill patients with exacerbations of these chronic conditions. Coupled with the severe dysfunction hospitals had (my hospital boarded patients for the greater part of my second year, and I routinely only saw 7-9 patients a shift bc we didn't have room, granted those were almost all resuscitations and critically ill patients that required ICU level care or step down care). Then in our third year, our hospital shifted it's focus on education to moving meat (obviously a crucial skill for us to be able to manage a department) and now we went from seeing 7-9 critically ill patients/shift, to now seeing 2pph + resuscitations + waiting room medicine. That coupled with our attendings having to deal with extraneous **** (the plethora of PT/CM/psych boarders), we didn't really have any teaching on shift (not even like chalk talks) and I think a lot of us felt the burnout from that + the lack of formal education which is a disaster recipe for passing a standardized exam and in general, doesn't pump out good EM docs. That and the spaced repetition from seeing volume only really came our PGY3 year so you get 1 "true year" of EM that emulated what prior years before COVID had, and imho, that's not enough.

 

[Franzd'Epinay]

First-time test takers in 2024 would've been in residency from 2020/2021 through 2024. I wonder how much of this is a Covid effect.

I know high school and college students were particularly wrecked academically by the school lockdowns during the pandemic. I suspect the direct effect would be lower for people who had already graduated med school when the pandemic hit, but perhaps the secondary social effects and altered clinical burden led to some downstream effects here?

 

[alpinism]

I'm not sure you can blame COVID since most people were residents after 2020 after ED volumes had rebounded back to normal levels.

I think a much bigger negative effect has been the severe dysfunction and boarding in most EDs for the past few years that has led to residents managing significantly less patients during shifts. No one likes to admit it but at many places residents will often see at most 5-10 Pts on shifts cause there simply aren't enough beds available to see any more patients. That's essentially a 50% decrease in patient contacts for residents when compared to previous residents that worked in functional EDs where it was common to manage large volumes of patients during shifts.

 

[thegenius]

I"m sure ABEM has a list of who failed and what residency they went to. If you group residency programs into 4 quartiles, I wonder what the results would show. I"m sure ABEM knows.

e.g. I bet the residency training suks at some of these newer programs.

 

[Papa Oso]

As someone who overstudied for this exam for fear of failure (6k rosh questions + 1k on incorrects), I still found the exam difficult for all of the wrong reasons. Short prompts, partial vitals given, poor writing etc. To the point that there were some questions where you are thinking to yourself “what the hell are they even asking.” The question quality between Rosh and ABEM are just completely night and day. If you knew the subject the Rosh was asking you on, you were going to get the question right unlike an ABEM question.

HCA residencies didn’t crop up just over the past year, so blaming “poor residency education” for the almost consistent drop and then sudden 6% drop in pass rate doesn’t make sense.

 

[RustedFox]

As someone who overstudied for this exam for fear of failure (6k rosh questions + 1k on incorrects), I still found the exam difficult for all of the wrong reasons. Short prompts, partial vitals given, poor writing etc. To the point that there were some questions where you are thinking to yourself “what the hell are they even asking.” The question quality between Rosh and ABEM are just completely night and day. If you knew the subject the Rosh was asking you on, you were going to get the question right unlike an ABEM question.

HCA residencies didn’t crop up just over the past year, so blaming “poor residency education” for the almost consistent drop and then sudden 6% drop in pass rate doesn’t make sense.

It's a six year downtrend, and for-profit residencies have been around for about the same timeframe.

Source: Me. Our new hires over the past 3-4 years have been pretty effing shaky. Many of them were from these "residencies."

 

[cyanide12345678]

I think i took my exam in 2020. It was fairly easy.

It’s the difference between being a top tier desirable specialty vs a bottom tier back up specialty.

i wont be surprised if it falls more as candidate quality has continued to drop.

 

[TooMuchResearch]

Shoot I'll add some more kindling to this. The new hires we've had come on since I graduated residency in 2018 absolutely trend lower in clinical competency. We staff 4 hospitals in a major metro and have had 4-5 huge rounds of hiring dating back the past 6 years. It's almost getting to be the exception rather than the rule that a new hire finds their footing and doesn't have any issues. A lot of our new hires are slow at best, occasionally incompetent at worse and not particularly trusted by the nursing staff.

We're lucky and still hire almost everyone from local residencies (not new ones) or good people with local ties that went to okay or better programs.

 

[doggydog]

I think i took my exam in 2020. It was fairly easy.

Niiiice

 

[trackrunner321]

If you look at the trend of scores decreasing, it does mirror the proliferation of subpar programs.

 

[Goro]

First-time test takers in 2024 would've been in residency from 2020/2021 through 2024. I wonder how much of this is a Covid effect.

I was wondering the same thing!

 

[gamerEMdoc]

If you look at the trend of scores decreasing, it does mirror the proliferation of subpar programs.

I think its a numbers game more than anything. As the number of programs increased, so increased the number of applicants, but not the number of super competitive applicants. I also think there's just a generational difference in the average resident these days in terms of the paranoia and/or even caring about failing. Some people flat out will say to your face "I'm not studying, I'll just wing it, and if I fail I'll just retake it". 20 years ago, that never happened, we were paranoid as **** bc when only a few percent failed, you didn't want to be singled out. Even those that do study often just say "I completed ROSH".

When I studied for the board, I completed NEMBR (which I also completed as a resident), memorized a review book (EM secrets) cover to cover, completed all of PEER for the 2nd or 3rd time, and made my own 20 page study guide which I had committed to memory. Now everyone looks at doing a couple thousand ROSH questions as the be all and end all of studying for the board and frankly ROSH is not that good of a product to accurately reflect the questions on the exam.

 

[gamerEMdoc]

I was wondering the same thing!

ITE and board pass rates have been declining since before COVID. And while COVID may have played a small part, I think there are larger issues at play. We need to stop blaming COVID for every single problem in society. If you can't pass a general medical knowledge test, it's not because of the pandemic. It's because you either have a knowledge base issue or didn't spend the time preparing. Maybe the pandemic had a hand in some of that, but its certainly not the main cause IMO.

 

[WhatJobDoIPick]

ITE and board pass rates have been declining since before COVID. And while COVID may have played a small part, I think there are larger issues at play. We need to stop blaming COVID for every single problem in society. If you can't pass a general medical knowledge test, it's not because of the pandemic. It's because you either have a knowledge base issue or didn't spend the time preparing. Maybe the pandemic had a hand in some of that, but its certainly not the main cause IMO.

Resident quality is declining as quality American grads are working up to the trash that is EM.

It's laughable that this speciality still requires audition rotations. Can you imagine asking an American grad with a Step 2 score of 250 to do an audition rotation for a dead field when they can match Rads without one and make 500k out the gate EASY.

 

[Brigade4Radiant]

EM has no business making people do away rotations or their SLOE. Family medicine doesn’t do it and it’s roughly as competitive as EM.

 

[Porfirio]

EM has no business making people do away rotations or their SLOE. Family medicine doesn’t do it and it’s roughly as competitive as EM.

Race to the bottom, sadly. Good thing I will be able to be done. Not sure who will take care of me when I get to be 65+, but it might be AI anyways.

 

[Apollyon]

Race to the bottom, sadly. Good thing I will be able to be done. Not sure who will take care of me when I get to be 65+, but it might be AI anyways.

I just laughed, thinking of AI telling you that your story, while lovely, needs to get to the point. And you can't even complain, because it's not alive!

 

[AlmostAnMD]

I just laughed, thinking of AI telling you that your story, while lovely, needs to get to the point. And you can't even complain, because it's not alive!

It'll be a boon, i think. I'm imagining every single ed room with a robodoc that pops out of the wall that will actually listen to old people ramble for 20 minutes while it's simultaneously seeing 80 other people in the department and charting at the same time. With that level of efficiency, people can finally relax and tell the ai doc the story of today's car accident started back in 'nam

 

[justwantin]

The new generation response is "It's biased and racist and not a fair representation of my skills as a clinician and first-generation low income immigrant minority with a real understanding of my patients' needs."

I will agree with you that residents across the board are softer now than ever. Much of the coddling comes from ensuring more patient safety for student learners. At the same time, lack of actually touching patients as students during clinical years hurts your learning curve in residency training as well.

However, i gotta push back on the biased/racist comment. I have never heard a resident, regardless of race/gender/etc, make such a claim about the exam. Have I heard about tone deaf residencies that have crossed the line for dark humor in the name of "coping"? Yes and it's disappointing. We definitely know our residents and students from low SES minority groups DO understand patients better than our more privileged learners. I mean... what's the point of prescribing meds if your patients don't trust/understand you?

 

[Emapp20177]

If you look at the trend of scores decreasing, it does mirror the proliferation of subpar programs.

Only partially. The trend is multifactorial and will continue to worsen:

- The average medical student is less competitive than in the past (wages not keeping up with inflation, bad hours and long buy in time, better alternatives (i.e. tech fields).
- EM is exponentially less competitive than it was historically. Remember it being one of the "EROADs" specialities? What a joke.
- The most recent class is >10% FMGs, second only to FM, when previously any FMGs matching was almost unheard of.
- Crazy lawsuits in the news, with EM being one of the highest for litigation.
- Stories about staffing companies leaving their contractors SOL (APP, NES).
- MDs no longer respected culturally.
- Fear of saturation of job market in coming years.
- Anecdotal, but the quality of residents as a whole has taken a big dip. Current generation is tough to teach for due to cultural shifts.
- Working harder, generating more RVUs, for a decrease in pay (see below).

 

[TooMuchResearch]

I think its a numbers game more than anything. As the number of programs increased, so increased the number of applicants, but not the number of super competitive applicants. I also think there's just a generational difference in the average resident these days in terms of the paranoia and/or even caring about failing. Some people flat out will say to your face "I'm not studying, I'll just wing it, and if I fail I'll just retake it". 20 years ago, that never happened, we were paranoid as **** bc when only a few percent failed, you didn't want to be singled out. Even those that do study often just say "I completed ROSH".

When I studied for the board, I completed NEMBR (which I also completed as a resident), memorized a review book (EM secrets) cover to cover, completed all of PEER for the 2nd or 3rd time, and made my own 20 page study guide which I had committed to memory. Now everyone looks at doing a couple thousand ROSH questions as the be all and end all of studying for the board and frankly ROSH is not that good of a product to accurately reflect the questions on the exam.

I remember reviewing the entire Atlas of EM the day before the exam to get those pictures in my head one last time before exam day. There was no winging it.

 

[JAFERD_MD]

I will agree with you that residents across the board are softer now than ever. Much of the coddling comes from ensuring more patient safety for student learners. At the same time, lack of actually touching patients as students during clinical years hurts your learning curve in residency training as well.

However, i gotta push back of the biased/racist comment. I have never heard a resident, regardless of race/gender/etc, make such a claim about the exam. Have I heard about tone deaf residencies that have crossed the line for dark humor in the name of "coping". We definitely know our residents and students from low SES minority groups DO understand patients better than our more privileged learners. I mean what's the point of prescribing meds if your patients don't trust/unstand you?

I think you (mostly) missed the joke.

 

[TooMuchResearch]

I think you (mostly) missed the joke.

Back in my day, you had to macroaggress people before anyone cared.

 

[RustedFox]

Back in my day, you had to macroaggress people before anyone cared.

It was a funny joke.

 

[Arcan57]

There's no substitute for reps. Good programs push those reps until you can start having an honest debate about whether seeing another x/y/z diagnosis represents a learning opportunity. For the stuff that you don't get reps on because they're super damn rare, good programs constantly talk about the zebras in a way that make it seem like there's one just around the corner so you'd better know what to do. Reps require volume, which is not always a given and the constant harping on zebras require attendings who care deeply about the knowledge base of the residents they're supervising. Finally you have to have a trainee that has the capacity to learn from the reps and cares about how their performance is perceived.

The dropping pass rates suggest one (or more) of the pillars are crumbling.

 

[RustedFox]

There's no substitute for reps. Good programs push those reps until you can start having an honest debate about whether seeing another x/y/z diagnosis represents a learning opportunity. For the stuff that you don't get reps on because they're super damn rare, good programs constantly talk about the zebras in a way that make it seem like there's one just around the corner so you'd better know what to do. Reps require volume, which is not always a given and the constant harping on zebras require attendings who care deeply about the knowledge base of the residents they're supervising. Finally you have to have a trainee that has the capacity to learn from the reps and cares about how their performance is perceived.

The dropping pass rates suggest one (or more) of the pillars are crumbling.

Master-level summary.

 

[TooMuchResearch]

I got enough reps in residency to frequently hate life. Could I still do a blind subclavian in a collared patient after 23 hours without sleep? I don't know, but I certainly hope I never have to find out. Laugh out loud.

 

[hoot504]

The reps thing nails it. I did an away at a low volume Ivy League and those residents were absolutely clinically inferior than the kids at some no name inner city program with dirt smudged on their faces who just did their third intubation for the shift.

One of those programs produces docs that can work anywhere, the other you’d be relegated to academics only.

 

[Arcan57]

The reps thing nails it. I did an away at a low volume Ivy League and those residents were absolutely clinically inferior than the kids at some no name inner city program with dirt smudged on their faces who just did their third intubation for the shift.

One of those programs produces docs that can work anywhere, the other you’d be relegated to academics only.

The biggest illusion training in a quaternary care center gives you is that because you're seeing patients with all these complicated diseases that means that YOU personally are proficient in managing all these complicated diseases. It's a lot easier to manage a CIDP patient's Trilogy when managing it involves calling the RT and the pulmologist that just do neuromuscular patients. Being a good EM doc is about making good decisions under suboptimal conditions. This is a skill that is best learned by making decisions under suboptimal conditions with some regularity.

 

[EctopicFetus]

The biggest illusion training in a quaternary care center gives you is that because you're seeing patients with all these complicated diseases that means that YOU personally are proficient in managing all these complicated diseases. It's a lot easier to manage a CIDP patient's Trilogy when managing it involves calling the RT and the pulmologist that just do neuromuscular patients. Being a good EM doc is about making good decisions under suboptimal conditions. This is a skill that is best learned by making decisions under suboptimal conditions with some regularity.

Agree. I have had interactions with some docs from these academic “powerhouses” they are super slow, cant make a decision and rarely are able to make decisions that arent obvious. Multiple phone calls to specialists who in the community have 0 interest in talking to you unless you have a meaningful question. Spending your residency taking care of “medically complex” patients doesnt make you a better doctor.

Seeing the 1,000th 57 year old with chest pain or belly pain and being able to distinguish the issue without ordering every test under the sun makes you a good doctor.

These academic types often order a crazy amount of completely stupid tests. Over time many of them can be untaught these habits but it is hard and makes me question the utility of these places.

In addition, the community hospitals care about metrics and throughput and none of the academic types I have worked with know a thing about that. I refuse to work with HCA trained people but I imagine they would be good at this.

They also lack any understanding about billing / coding. Their charts are trash from a med mal protection standpoint and from billing. Again, this can be taught but it is scary whats out there.